=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700757952
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ETX PSYCHIATRIC SPECIALISTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2025
-----------------------------------------------------
Last Update Date | 09/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4010 CLOVERDALE DR
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-242-7129
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4010 CLOVERDALE DR
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701-9314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-242-7129
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MATTHEW RICH
-----------------------------------------------------
Credential | MSN, APRN, AGCNS-BC
-----------------------------------------------------
Telephone | 480-242-7129
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084B0040X
-----------------------------------------------------
Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------